Advertisment Polium-B
Indian Journal of Critical Care Medicine
An open access publication of ISCCM™ 
Users online: 2261 
     Home | Login 
  About Current Issue Archive Search Instructions Online Submission Subscribe Etcetera Contact  
 »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
 »  Article in PDF (756 KB)
 »  Citation Manager
 »  Access Statistics
 »  Reader Comments
 »  Email Alert *
 »  Add to My List *
* Registration required (free) 

  IN THIS Article
 »  Abstract
 » Introduction
 »  Materials and Me...
 » Results
 » Discussion
 » Conclusions
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    PDF Downloaded581    
    Comments [Add]    
    Cited by others 2    

Recommend this journal


 Table of Contents    
Year : 2013  |  Volume : 17  |  Issue : 1  |  Page : 23-27

Intensive care nurses' opinions and practice for oral care of mechanically ventilated patients

1 Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan, Iran
2 Department of Nursing, Fatemahtalzahra Hospital of Najafabad, Social Security Organization, Isfahan, Iran

Date of Web Publication17-May-2013

Correspondence Address:
Mohsen Adib-Hajbaghery
Trauma Nursing Research Center, Kashan University of Medical Sciences, Kashan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0972-5229.112154

Rights and Permissions

 » Abstract 

Context: Oral care is an essential aspect of critical care nursing. However, no study has been published on oral care practice of Iranian and Asian nurses. The majority of published studies were conducted in western and European countries. Aims: This study aimed to evaluate the nurses' opinions and practice about oral care in patients under mechanical ventilation. Settings and Design: A cross-sectional study was conducted on 130 intensive care nurses from 6 intensive care units in the university hospitals of Iran. Materials and Methods: A questionnaire was used to gather the data and charts of 45 patients were evaluated. Statistical analysis: Descriptive statistical analysis are presented. Results: Oral care obtained the 7 th rank in prority and a mean score of 5.7 on a scale of 1-10. More than 21% of subjects did not perform oral care in their usual duties. High load of writing tasks and personnel shortages were the major barriers to oral care. Only 20% of the patients' charts contained a report on oral care. Conclusions: Nurses did not consider oral care in intensive care patients as a high priority. This result highlights the need to continue education programs on oral care for improving the knowledge and attitude of intensive care nurses with respect to oral care.

Keywords: Critical care, mechanical ventilation, oral care, nurses′ opinions

How to cite this article:
Adib-Hajbaghery M, Ansari A, Azizi-Fini I. Intensive care nurses' opinions and practice for oral care of mechanically ventilated patients. Indian J Crit Care Med 2013;17:23-7

How to cite this URL:
Adib-Hajbaghery M, Ansari A, Azizi-Fini I. Intensive care nurses' opinions and practice for oral care of mechanically ventilated patients. Indian J Crit Care Med [serial online] 2013 [cited 2018 Jul 17];17:23-7. Available from:

 » Introduction Top

Oral care is an essential aspect of critical care nursing. [1] Poor oral care can affect communication and nutritional intake and may cause pain and oral and respiratory infections in intensive care unit (ICU) patients. [2]

Although nurses rank oral care a high priority, there is a theory-practice gap in relation to nurse administered oral hygiene, [3],[4],[5] and oral care methods are not consistent with the current research. [4],[6],[7] This gap has attributed to inadequate training or lack of written protocols. [8],[9],[10] To the best of our knowledge, no study has been published on oral care practice of Iranian and Asian nurses. The majority of published studies have been conducted in western and European countries. This study aimed to evaluate the opinions and practice of Iranian nurses about oral care in ICU patients under mechanical ventilation.

 » Materials and Methods Top

A descriptive cross-sectional study was conducted on 130 ICU nurses in selected university hospitals of Iran. Inclusion criteria included having at least 1 year of nursing experience, working in ICU for at least 6 months, and consent to participate. Using a simple random sampling method, 50% of the nurses in each unit were selected from a list of nurses working in each unit. A new randomly selected nurse from the same unit was recruited if a nurse did not consent to participate.

Ethical considerations

The ethical aspects of the research were approved by the Institutional Review Board. All nurses signed the written informed consent and were assured of confidentiality.

Data collection

A two-part questionnaire was used to gather data (see appendix)-[Additional file 1]. The first part contained questions about demographics including gender, age, years of working in ICU, the highest qualification, and the nurses' history of training on oral care. The second part included 8 questions. The first 3 questions were about the frequency of oral assessment and oral care through the usual working shift and the nurses' beliefs about the goal of oral care. The 4 th and 5 th questions were in yes/no format and were about using a checklist for oral care and documentation of oral care immediately after the care was done. A list of ten essential nursing care (including tracheal suctioning, skin care, eye care, oral care, bowel care, writing reports, helping or doing personal hygiene for mechanically ventilated patients, care for catheters, nutrition, and preventing sensory overload) was asked in question 6, and the nurses were required to score themselves from 1 to 10, with a higher score indicating more importance for care. The question 7 was in visual analog format and consisted of several 100 mm columns representing 12 common materials used in oral care (including cotton swabs, pieces of cotton gauze, normal saline, tape water, mixture of lemon water and glycerin, oxygen peroxide, cholrohexidine, betadine, petroleum jelly, tooth brush, toothpaste, and simple oral suctioning). Descriptors were placed at each end of columns (100 = highest frequency of using; 1 = lowest frequency of using). Nurses were asked to mark an X on place that corresponded with the frequency of using each material in oral care. The question 8 was consisted of a list of 10 common barriers for practicing good oral care that were extracted from previous literature. Nurses were asked to score themselves from 1 to 10, with a higher score for items considered more important barrier to oral care. The questionnaires were given to the nurses and were gathered on their next shift.

Content validity of the questionnaire was confirmed by 10 nurse educators and 2 ICU tutors. Reliability of instruments was also checked by test-retest on ten nurses at a 2-week interval (r = 0.79).

Also, nursing records of 45 patients were evaluated for the numbers and the content of oral care reports. For this purpose, two rounds (on 2 consecutive days) were conducted in each unit, and the nursing records of patients who had at least 1-day long stay and were under mechanical ventilation were evaluated by the second author.

 » Results Top

A total of 99 female and 31 male nurses participated in this study, with a mean age of 31.5 ± 5.9 years and a mean experience in ICU of 6.5 ± 4.1 years. Of them, 110 nurses had a Bachelor of Science in nursing, 9 had Master of Science in nursing, and 11 had nursing diploma. About one-third of the participants had a history of post-basic training on oral care for ICU patients. On a scale of 1-10, nurses rated oral care with a score of 5.7 that was the seventh priority among the ten nursing care functions [Table 1]. Only about 21% of nurses marked the "prevention of ventilator-associated pneumonia" (VAP) as the aim of oral care. Also, 21.5% stated that they do not administer oral care for patients, and only 16.2% stated that they use a special written checklist for administering oral care [Table 1]. The common means employed for oral care were simple suctioning (83.8%) followed by normal saline swabs (69.2%) and cholrohexidine paint (53.8%); however, tooth brush was only used in 14.6% of cases for oral care [Table 2]. The most important barriers to oral care for patients under mechanical ventilation were "too much writing tasks" followed by "lack of time" and "staff shortage" [Figure 1]. More than 86% of nurses stated that they recorded all oral care practices; however, no documentation of oral care was found in the records of 44.4% of patients in the 2-day evaluation tour [Figure 2].
Table 1: Nurses' reports of oral care-its rank, goal and assessment

Click here to view
Table 2: Nurses' reports of materials used in oral care

Click here to view
Figure 1: The nurses' ranking of barriers

Click here to view
Figure 2: Frequency of recording oral care

Click here to view

 » Discussion Top

This was the first study on oral care in ICU patients in Iran. Nurses participating in this study did not rank oral care in ICU patients as a high priority. They ranked oral care as 7 th among 10 nursing care functions, while endotracheal tube suctioning and writing of reports were ranked higher. This finding is consistent with previous reports from other countries. Grap et al., [11] and DeKeyser Ganz et al., [3] also reported that the majority of ICU nurses did not rank oral care as a high priority. [3],[11] However, our nurses ranked oral care lower than that in other studies. Because of the important role of good oral care in prevention of VAP, [4],[12] these findings suggest the need for educating nurses in this area.

The majority of nurses in this study believed that the provision of patient comfort and personal hygiene are the aims of practicing oral care in ICU patients. This finding consistent with previous reports suggests that nurses do not have up-to-date knowledge of oral care for ICU patients, [3],[11],[12],[13],[14],[15] do not have the knowledge-base for deciding the time, frequency and correct methods of oral care, [11] and that the educational courses did not prepare them for practicing quality oral care for mechanically ventilated patients. [13],[15]

More than two-third of nurses in the present study stated that they did not pass any post-basic special training in oral care. This finding is alarming and is not consistent with studies done in Europe and United Kingdom (UK), where the majority of ICU nurses have passed post-basic training programs on oral care. [1],[16] It seems that lack of up-to-date knowledge on oral care has significantly affected the nurses' ranking of the oral care priority. It would appear from these data that nursing training programs with focus on oral care might change nursing knowledge and attitudes.

The majority of nurses in this study stated that they always recorded all oral care in their nursing notes; however, no report on oral care was found in 44.44% of the patients' charts. This finding is consistent with the results of Grap et al., [11] Sole et al., [10] and Hanneman and Gusick [17] found discrepancies between what the ICU nurses stated and the content of nursing reports. However, studies have shown that performing and recording oral care are associated with reduced incidence of VAP. [6],[17],[18]

Although the rate of recording oral care in this study was higher than that in other reports, most cases have been recorded briefly, and/or several times of oral care were recorded as one brief note. Also, it appears that 44% of patients did not receive oral care or the oral care was not recorded because it was not considered important. This finding shows the need to monitor nursing care and especially with respect to oral care to document accurately.

More than one-fifth of the nurses stated that they do not assess the patients' oral cavity or attempt oral care during their working shifts. Also, only about 16% of nurses reported that they use a written checklist for oral care. This finding is consistent with others and again demonstrates the nurses' poor knowledge and attitude towards oral care. Studies have shown that establishment of protocols along with educational programs could improve the nurses' knowledge and clinical practice of oral care. [19],[20] DeKeyser Ganz et al., [3] also cited the lack of a protocol to be the main reason for ignorance of oral care in ICUs. Other studies have also reported that no protocol is being used for oral care of orally intubated patients in more than half of the ICU wards in Europe and that oral care policies and practices vary from hospital to hospital and even within ICUs. In addition, protocols guiding oral care are inconsistent, impractical, or difficult to follow.­ [10],[21] These findings suggest the need for developing specific protocols for oral care.

Our nurses cited "too much writing tasks," "lack of time," and "personnel shortage" as the most important obstacles to oral care. According to Schwartz and Powell, nurses' fears of endotracheal tube dislodgement, aspiration and patient discomfort, along with the nurse's lack of time and knowledge, and the perception that oral care has a low priority are the main barriers to proper oral care in critically ill patients. [22] It is also reported that factors such as inadequate education, unavailability of supplies and equipment, [23],[24] poor management, [9] lack of a standard protocol, lack of sufficient time, shortage of nurses, overcrowding of units, excessive workload [25],[26] and poor knowledge and attitudes [13],[27],[28] all affect the type and the quality of oral care.

Our study showed that simple oral suctioning was the most frequent method of oral care in mechanically ventilated patients. Toothbrush was used only in about 15% of cases despite the recommendation that it is the best method for removing dental plaques in ICU patients. [29] Chlorhexidine was reported to be better than tooth brushing in reducing VAP; [30] however, several investigations have shown that mechanical interventions, particularly tooth brushing, are more effective than using swabs or a oralwash with chlorhexidine. [3],[29],[31],[32] Tooth brushing was only prohibited in patients with coagulation disorders or severe oral ulcers. [15]

Because of the possible effects of the researcher's presence on the practice of nurses, the nursing notes in the patients' charts were used to assess the nurses' performance; however, a prospective observational study may more accurately reflect the nurses' practice on oral care in ICU patients.

 » Conclusions Top

The study indicated that most nurses ranked oral care as a low priority in intensive care patients. Too much writing duties, lack of time, and personnel shortages were mentioned as the most important barriers in practicing oral care. It seems that nurses do not have evidence-based knowledge of the importance and correct manner of oral care. Some in-service training programs along with strengthening the supervisory efforts is recommended.

 » References Top

1.Jones H, Newton JT, Bower EJ. A survey of the oral care practices of intensive care nurses. Intensive Crit Care Nurs 2004;20:69-76.  Back to cited text no. 1
2.Evans G. A rationale for oral care. Nurs Stand 2001;15:33-6.  Back to cited text no. 2
3.DeKeyser Ganz F, Fink NF, Raanan O, Asher M, Bruttin M, Nun MB, et al. ICU nurses' oral-care practices and the current best evidence. J Nurs Scholarsh 2009;41:132-8.  Back to cited text no. 3
4.Blot S, Vandijck D, Labeau S. Oral care of intubated patients. Clin Pulm Med 2008;15:153-60.  Back to cited text no. 4
5.Johnstone L, Spence D, Koziol-McClain J. Oral hygiene care in the pediatric intensive care unit: Practice recommendations. Pediatr Nurs 2010;36:85-96.  Back to cited text no. 5
6.Binkley C, Furr LA, Carrico R, McCurren C. Survey of oral care practices in US intensive care units. Am J Infect Control 2004;32:161-9.  Back to cited text no. 6
7.Berry AM, Davidson PM, Masters J, Rolls K. Systematic literature review of oral hygiene practices for intensive care patients receiving mechanical ventilation. Am J Crit Care 2007;16:552-62.  Back to cited text no. 7
8.McNeill HE. Biting back at poor oral hygiene. Intensive Crit Care Nurs 2000;16:367-72.  Back to cited text no. 8
9.Adib-Hajbaghery M, Ansari A, Azizi-Fini E. Oral care in ICU patients: A review of research evidence. Feyz KAUMS J 2011;15:280-93.  Back to cited text no. 9
10.Sole ML, Byers JF, Ludy JE, Zhang Y, Banta CM, Brummel K. A multisite survey of suctioning techniques and airway management practices. Am J Crit Care 2003;12:231-2.  Back to cited text no. 10
11.Grap MJ, Munro CL, Ashtiani B, Bryant S. Oral care interventions in critical care: Frequency and documentation. Am J Crit Care 2003;12:113-8.  Back to cited text no. 11
12.Berry AM, Davidson PM. Beyond comfort: Oral hygiene as a critical nursing activity in the intensive care unit. Intensive Crit Care Nurs 2006;22:318-28.  Back to cited text no. 12
13.Allen Furr L, Binkley CJ, McCurren C, Carrico R. Factors affecting quality of oral care in intensive care units. J Adv Nurs 2004;48:454-62.  Back to cited text no. 13
14.Jelic S, Cunningham JA, Factor P. Clinical review: Airway hygiene in the insensitive care unit. Crit Care 2008;12:209.  Back to cited text no. 14
15.Abidia RF. Oral care in the intensive care unit: A review. J Contemp Dent Pract 2007;8:76-82.  Back to cited text no. 15
16.Rello J, Koulenti D, Blot S, Sierra R, Diaz E, De Waele JJ, et al. Oral care practices in intensive care units: A survey of 59 European ICUs. Intensive Care Med 2007;33:1066-70.  Back to cited text no. 16
17.Hanneman SK, Gusick GM. Frequency of oral care and positioning of patients in critical care: A replication study. Am J Crit Care 2005;14:378-86.  Back to cited text no. 17
18.Mori H, Hirasawa H, Oda S, Shiga H, Matsuda K, Nakamura M. Oral care reduces incidence of ventilator-associated pneumonia in ICU populations. Intensive Care Med 2006;32:230-6.  Back to cited text no. 18
19.Adib Haj Bagheri M, Salsali M, Ahmadi F. Clinical Decision-making: A way to professional empowerment in nursing. IJME 2004;10:3-12.  Back to cited text no. 19
20.Garcia R, Jendresky L, Colbert L, Bailey A, Zaman M, Majumder M. Reducing ventilator-associated pneumonia through advanced oral-dental care: A 48-month study. Am J Crit Care 2009;18:523-32.  Back to cited text no. 20
21.Feider LL, Mitchell P. Validity and reliability of an oral care practice survey for the orally intubated adult critically ill patient. Nurs Res 2009;58:374-7.  Back to cited text no. 21
22.Schwartz AJ, Powell S. Brush up on oral assessment and care. Nursing 2009;39:30-2.  Back to cited text no. 22
23.Moore J. Assessment of nurse-administered oral hygiene. Nurs Times 1995;91:40-1.  Back to cited text no. 23
24.Curzio J, McCowan M. Getting research into practice: Developing oral hygiene standards. Br J Nurs 2000;9:434-8.  Back to cited text no. 24
25.Buerhaus PI, Staiger DO, Auerbach DI. Why are shortages of hospital RNs concentrated in specialty care units? Nurs Econ 2000;18:111-6.  Back to cited text no. 25
26.Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA 2002;288:1987-93.  Back to cited text no. 26
27.Dalton JA, Carlson J, Mann JD, Blau W, Bernard S, Youngblood R. An examination of nursing attitudes and pain management practices. Cancer Pract 1998;6:115-24.  Back to cited text no. 27
28.Román EM, Sorribes E, Ezquerro O. Nurses' attitudes to terminally ill patients. J Adv Nurs 2001;34:338-45.  Back to cited text no. 28
29.Pedreira ML, Kusahara DM, de Carvalho WB, Núñez SC, Peterlini MA. Oral care interventions and oropharyngeal colonization in children receiving mechanical ventilation. Am J Crit Care 2009;18:319-28.  Back to cited text no. 29
30.Munro CL, Grap MJ, Jones DJ, McClish DK, Sessler CN. Chlorhexidine, toothbrushing, and preventing ventilator-associated pneumonia in critically ill adults. Am J Crit Care 2009;18:428-37.  Back to cited text no. 30
31.Fields LB. Oral care intervention to reduce incidence of ventilator-associated pneumonia in the neurologic intensive care unit. J Neurosci Nurs 2008;40:291-8.  Back to cited text no. 31
32.Hajibagheri A, Azizi Fini I. Oral Care in Patients Receiving Mechanical Ventilation: A Systematic Review. Nurs Midwifery Stud. 2012;1:51-61.  Back to cited text no. 32


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]

This article has been cited by
1 Oral care for intubated patients: a survey of intensive care unit nurses
Norkhafizah Saddki,Farah Elani Mohamad Sani,Mon Mon Tin-Oo
Nursing in Critical Care. 2014; : n/a
[Pubmed] | [DOI]
2 Oral Care in Trauma Patients Admitted to the ICU: Viewpoints of ICU Nurses
Seyed Alireza Javadinia,Zahra Kuchi,Alireza Saadatju,Mohsen Tabasi,Mohsen Adib- Hajbaghery
Trauma Monthly. 2014; 19(2)
[Pubmed] | [DOI]


Print this article  Email this article
Online since 7th April '04
Published by Wolters Kluwer - Medknow